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Citation Lu, Chunling, Zhihui Li, and Vikram Patel. 2018. “Global childand adolescent mental health: The orphan of developmentassistance for health.” PLoS Medicine 15 (3): e1002524.doi:10.1371/journal.pmed.1002524. http://dx.doi.org/10.1371/journal.pmed.1002524.

Published Version doi:10.1371/journal.pmed.1002524

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POLICY FORUM

Global child and adolescent mental health:

The orphan of development assistance for

health

Chunling Lu1,2,3*, Zhihui Li4, Vikram Patel2

1 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of

America, 2 Department of Global Health and Social Medicine, Harvard Medical School, Boston,

Massachusetts, United States of America, 3 Department of Science and Technology-National Research

Foundation (DST-NRF) Center of Excellence in Human Development, University of Witwatersrand,

Johannesburg, South Africa, 4 Department of Global Health and Population, Harvard T.H. Chan School of

Public Health, Boston, Massachusetts, United States of America

* chunling_lu@hms.harvard.edu

Summary points

• One-quarter of disability-adjusted life years (DALYs) for mental disorders and sub-

stance abuse is borne by those 24 years old or younger, the age group that accounted for

more than 40% of the world population. Using the aid activities database from the Cred-

itor Reporting System (CRS), we estimated the level of development assistance for child

and adolescent mental health (DAMH_CA) in 132 developing countries between 2007

and 2015.

• The total amount of DAMH_CA with a primary target on child and adolescent mental

health was US$190.3 million over the 8 years, accounting for 12.5% of total development

assistance for mental health (DAMH) and 0.1% of development assistance for health

(DAH).

• The largest investments in DAMH_CA over this 8-year period were disbursed to the

humanitarian assistance sector for children and adolescents in disasters or conflicts (US

$77.2 million [41% of DAMH_CA]), followed by the sector of government and civil ser-

vices (US$58.6 million [31%]), the health sector (US$38.0 million [20%]), and the edu-

cation sector (US$15.6 million [8%]).

• Donors invested little in child and adolescent mental health, in both absolute amount

and fraction.

• The donor community should substantially increase DAMH_CA to establish and

enhance the capacity for delivering mental health care to this demographic group.

Background

More than 40% of the world population is 24 years old or younger, the vast majority of whom

live in low- and lower middle–income countries [1]. Globally, a quarter of disability-adjusted

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 1 / 12

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OPENACCESS

Citation: Lu C, Li Z, Patel V (2018) Global child and

adolescent mental health: The orphan of

development assistance for health. PLoS Med 15

(3): e1002524. https://doi.org/10.1371/journal.

pmed.1002524

Published: March 9, 2018

Copyright: © 2018 Lu et al. This is an open access

article distributed under the terms of the Creative

Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in

any medium, provided the original author and

source are credited.

Data Availability Statement: All aid data files are

available from the Creditor Reporting System

database. The link is https://stats.oecd.org/Index.

aspx?DataSetCode=CRS1. All population data are

available from the United Nation Population

Division. The link is https://esa.un.org/unpd/wpp/.

Funding: This study was funded by NIH 1K0HD07

1929-01 https://www.nih.gov The funders had no

role in study design, data collection and analysis,

decision to publish, or preparation of the

manuscript.

Competing interests: VP is a member of the

Editorial Board of PLOS Medicine.

Abbreviations: BMGF, Bill & Melinda Gates

Foundation; CRS, Creditor Reporting System; DAC,

Development Assistance Committee; DAH,

development assistance for health; DALY,

life years (DALYs) for mental disorders and substance abuse is borne by this age group [2],

and about 75% of mental disorders diagnosed in adulthood have their onset before the age of

24 years [3]. Most children and young people in developing countries, however, do not have

access to mental health care.

Lack of financial commitment is amongst the major barriers for improving access to mental

health interventions in developing countries. Unsurprisingly, the least resourced regions and

countries in the world rely heavily on development assistance, typically from high-income

countries or foundations, to support the health sector. Our previous study on development

assistance for mental health (DAMH) demonstrated that DAMH remained low both in abso-

lute terms and as a proportion of development assistance for health (DAH) between 2007 and

2013 [4].

This analysis extends our previous analysis by investigating development assistance for

child (below age 10) and adolescent (between age 10 and 24) mental health (DAMH_CA). We

tracked the level of DAMH_CA in 132 countries between 2007 and 2015 (S1 Table).

Estimating DAMH_CA between 2007 and 2015

Data sources

We used the Organization for Economic Co-operation and Development (OECD) Creditor

Reporting System (CRS) aid activity database [5], which was downloaded in May 2017. The

CRS database is publicly accessible and provides information on aid activities reported directly

by the governments of the 26 members of the Development Assistance Committee (DAC),

multilateral organizations (e.g., World Bank), global health initiatives (e.g., GAVI, the Vaccine

Alliance), non-DAC countries (e.g., United Arab Emirates), and private donors (the Bill &

Melinda Gates Foundation [BMGF]) [5,6]. See S1 Text for more details on data sources. Our

analysis included 132 countries (S1 Table) founded by 44 donors.

Identifying projects on child and adolescent mental health

We defined DAMH_CA as aid disbursed to projects that either primarily or partially targeted

the promotion of mental health or the prevention and treatment of mental disorders for chil-

dren or adolescents. We adopted a multi-sectoral perspective [4,7] and included mental health

projects in non-health sectors such as education, government and civil services, and humani-

tarian assistance.

CRS data do not have a variable to indicate mental health projects for children and adoles-

cents but has three variables (project title, short description, and long description) that allowed

us to identify such projects with a list of key words (S2 Table) used in the previous studies

[4,8]. Key word searches were performed for projects in the sectors listed in Table 1. The defi-

nition of these sectors in the CRS can be found in S1 Box. Details on identification strategy are

presented in S1 Text.

Analyzing DAMH_CA

We followed the approach from an earlier study [7] and constructed two sets of estimates: one

including the full disbursements of multi-target projects (the upper bound of estimated aid for

DAMH_CA, presented in the Supporting information and the other (the lower bound of esti-

mated aid for DAMH_CA, presented in the text), which included only projects with a primary

target of promoting mental health for children and adolescents. We used actual disbursements

(grants and loans) rather than commitments to estimate DAMH_CA. The time frame allowed

us to both track changes in DAMH_CA since The Lancet published its first series on mental

Development assistance for child and adolescent mental health

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 2 / 12

disability-adjusted life year; DAMH, development

assistance for mental health; DAMH_CA,

development assistance for child and adolescent

mental health; EU, European Union; GFATM, Global

Fund to Fight AIDS, Tuberculosis and Malaria;

LMIC, low- and middle-income country; NGO,

nongovernmental organization; OECD, Organization

for Economic Co-operation and Development;

USD, US dollar.

Provenance: Not commissioned; externally peer

reviewed.

Table 1. Sectors for identifying DAMH_CA projects: Frequency and the two most common themes.

Sectors

Projects with the primary purpose on DAMH_CA (lower

bound), N = 1,384

Projects primarily or partially on DAMH_CA (upper bound), N = 4,009

Frequency

(Percentage) of

Total Projects

Two most common themes Frequency

(Percentage) of Total

Projects,

Two most common themes

Education

Basic Education 65 (4.70%) Establish psycho-pedagogical

research center for special

educational needs;

Educate and train students with

mental disabilities

423 (10.55%) Help teenagers grow and enhance their mental and

physical health;

Increase parents’ knowledge of early childhood

development, including cognitive, socio-emotional,

linguistic, and physical aspects

Secondary Education 16 (4.70%) Provide special assistance to

traumatized children;

Provide support to young children

to treat or prevent traumatizing

92 (2.29%) Emotional service for children, along with education,

effort, medical service, and cultural exchange;

Raise awareness of children’s reaction to violence and

war, prevent/minimize the long-term effects of trauma

Postsecondary

Education

22 (1.59%) Project targeting disruptive behavior

and attention disorders of childhood

and adolescence;

Provide primary care for youth with

mental illness

39 (0.97%) Improve school performance to favor the harmonic

physical and psychological development of

disadvantaged children;

Support public institutions to provide youth with

appropriate psychological and social expertise

Education, Level

Unspecified

36 (2.60%) Construction of a center for children

with autism;

Psychological intervention and

development project for poor

university students

148 (3.69%) Provide activities to help enhance youths’ mental and

physical health;

Provide school-based interventions to improve child

cognitive and psychosocial development and physical

and nutritional health and increase school enrollment

rate

Health

General Health 225 (16.26%) Improving psychological healthcare

for children;

Address negative effects of alcohol

and drug use among children and

youth

384 (9.58%) Provide treatment and psychological support for HIV/

AIDS patients;

Improve physical, nutritional, and psychological

services for preschool-aged children

Basic Health 88 (6.36%) Provide psychosocial care for young

children;

Support a therapy and support

center for children with autism

338 (8.43%) Improve growth and development of children under 6

years old in terms of nutrition, health, psychosocial,

and cognitive aspects;

Seek to reach children who have both physical and

mental disabilities

Population and

Reproductive Health

35 (2.53%) Monitor and promote psychosocial

care among young children;

Provide psychosocial care for

children and orphans living with

chronic illness

497 (12.40%) Address the HIV- and AIDS-related needs of high-risk

populations, including drug users, sex workers, and

orphans;

Provide psychosocial and medical support for people to

live with HIV/AIDS

Government and Civil

Service

Government and Civil

Society

149 (10.77%) Control tobacco and alcohol use

among children and young people;

Improve well-being of children and

youth traumatized by displacement

and war

482 (12.02%) Address educational and psychosocial impact of armed

conflict, build child protection network, promote

rights-based work;

Improve physical and mental health of women victims

of domestic violence and their children

Conflict, Peace, and

Security

44 (3.18%) Improve psychological healthcare

for children;

Ensure psychological and social

support in reintegration in home

communities

126 (3.14%) Provide interventions (psychosocial and medical, and

vocational training) for women and child soldiers;

Provide jobs, training, funding for income generation

and offer remedial schooling, trauma counseling, and

family reintegration

Other Social

Infrastructure and

Services

(Continued)

Development assistance for child and adolescent mental health

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 3 / 12

health and adolescent health [9,10] and to avoid the issue of missing disbursement data in the

CRS [6].

We identified the number of projects in each subsector and provided examples of the two most

commonly funded themes in the subsector. We estimated levels and changes of DAMH_CA, for

each country as well as for the sum of all countries, between 2007 and 2015 in both total and per

capita spending, with their upper and lower bounds. We tracked changes in DAMH_CA by sec-

tors, donors, channels of aid delivery (implementing agency), and countries between 2007 and

2015. For projects with missing channels (516 projects, cumulatively [13%]), we assumed they

were delivered by donors and replaced the channels according to donor categories. When conduct-

ing estimations at the country level, we excluded projects not allocable to a specific country.

Table 1. (Continued)

Sectors

Projects with the primary purpose on DAMH_CA (lower

bound), N = 1,384

Projects primarily or partially on DAMH_CA (upper bound), N = 4,009

Frequency

(Percentage) of

Total Projects

Two most common themes Frequency

(Percentage) of Total

Projects,

Two most common themes

Other Social

Infrastructure and

Services

404 (29.19%) Establish a specialized resource

center for preschool- and school-age

autism service organizations;

Raise awareness of the effects of

drug abuse among youths

709 (17.69%) Improve education and work performance, address

delays in children’s cognitive development;

Provide comprehensive care for children and

adolescents for the prevention of antisocial behavior,

violence, improper use of drugs and alcohol, and HIV/

AIDS

Humanitarian Aid

Emergency Response 252 (18.21%) Provide psychological diagnostics

and rehabilitation;

Provide psychosocial assistance to

earthquake-affected children

585 (14.59%) Establish children-friendly spaces and provide

psychosocial support for children;

Provide life skills education and psychosocial support

for conflict-affected children and adolescents

Reconstruction Relief

and Rehabilitation

17 (1.23%) Provide support and mental health

enhancement for children and

families;

Provide care for traumatized

children and adolescents

29 (0.72%) Provide physical, psychological, and social support for

Syrian refugee children and families;

Establish a multifunctional social center to provide

social services, including hairdresser services and

psychosocial care and consultation for children

Disaster Prevention

and Preparedness

5 (0.36%) Provide prevention of post-

traumatic disorders for children and

adolescents;

Provide psychosocial interventions

for children

15 (0.37%) Teach communities how to decrease vulnerability and

physical and spiritual trauma;

Give access to quality basic education for post-

earthquake children, along with psychosocial and

pedagogical support

Other Multisector

Other Multisector 21 (1.52%) Establish residential center for

psychosocially high-risk children;

Help children overcome trauma

through psychological and social

recovery actions

91 (2.27%) Community-based initiatives to treat depression and

provide AIDS prevention for girls;

Enable women and girls to recover their self-esteem, to

know their rights, to reintegrate them socially, and to

improve their living conditions

Unallocated/

Unspecified

Unallocated/

Unspecified

5 (0.36%) Provide psychosocial support for

child refugees;

Provide community-based

protection services and psychosocial

support for children

51 (1.27%) Provide basic physical care, palliative care, psychosocial

support, and counseling, with a particular focus/

concern for orphans and vulnerable children;

Increase parents’ knowledge in cognitive, socio-

emotional, linguistic, and physical aspects of early

childhood development

Abbreviation: DAMH_CA, development assistance for child and adolescent mental health.

https://doi.org/10.1371/journal.pmed.1002524.t001

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We paid special attention to DAMH_CA that targeted suicide and the five types of mental

disorders that are the leading causes for disability or death among the children and adolescents

group: (1) anxiety, (2) autism, (3) depression, (4) substance abuse, and (5) trauma [11,12].

All disbursements are in 2013 US dollars (USDs). STATA 14 was used in analysis.

Themes supported by DAMH_CA

We identified 1,384 DAMH_CA projects with primary targets on child and adolescent men-

tal health (lower bound). Among them, 404 were allocated to “Other Social Infrastructure

and Services,” and the most common themes were in providing special care for children

with autism and raising awareness of drug abuse among youths. There were 252 projects for

“Emergency Response,” with the most common themes being providing psychosocial assis-

tance and care to children in disasters or conflict areas. There were 225 projects for “Gen-

eral Health,” with the most common themes being improving psychological healthcare for

children and addressing alcohol and drug use among adolescents. There were 149 projects

for “Government and Civil Society,” with the most common themes being controlling

tobacco and alcohol use and improving well-being for children and youth affected by wars

(Table 1).

Absolute and relative DAMH_CA, lower-bound estimates

Between 2007 and 2015, a total of US$190.3 million was disbursed to projects with the primary

purpose of improving the mental health of children and adolescents, accounting for 12.5% of

DAMH and 0.10% of the total DAH disbursed over this period. The DAMH_CA increased

from US$6.6 million in 2007 to US$30.2 million in 2015, with fluctuations over time. The per-

centages of DAMH_CA in total DAMH increased from 10% in 2007 to 17% in 2008 and

dropped to 6% in 2013. In 2015, 14% of DAMH was for child and adolescent mental health

(Fig 1).

Fig 1. DAMH_CA by year (million, 2013 USD) and DAMH_CA disbursements as percentages of total DAMH,

lower-bound estimates. DAMH, development assistance for mental health; DAMH_CA, development assistance for

child and adolescent mental health, USD, US dollar.

https://doi.org/10.1371/journal.pmed.1002524.g001

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Sectors receiving DAMH_CA, lower-bound estimates

The humanitarian aid sector received the largest cumulative DAMH_CA, with a total amount

of US$77.2 million (40.5% of total DAMH_CA), followed by the government and civil society

sector (US$58.6 million [30.8%]), the health sector (US$38.0 million [20.0%]), and the educa-

tion sector (US$15.6 million [8.2%]) (Fig 2). In terms of each sector’s proportion in

DAMH_CA, government and civil services had the largest proportion in 2007 and 2008. It was

then replaced by humanitarian assistance between 2009 and 2014 and returned to the leading

position in 2015 (38.4% in total DAMH_CA in 2015), followed closely by “Humanitarian Aid”

(37.9%), “Health” (18.3%), and “Education” (5.4%).

DAMH_CA channels and donors, lower-bound estimates

In terms of channel of delivery, from 2007 to 2015, nongovernmental organizations (NGOs)

and civil society received the largest cumulative DAMH_CA of US$110.6 million (58.1% of

total DAMH_CA), followed by UN organizations and WHO (US$46.4 million [24.4%]); the

public sector in recipient countries received a relatively small fraction (US$23.1 million

[12.1%]) (see S2 Fig).

The top three donors were European Union (EU) institutions (US$44.8 million), Germany

(US$21.8 million), and Switzerland (US$18.6 million). During the analysis period, they

together provided between 32.1% and 71.7% of total DAMH_CA each year, with a mean of

51.5% (S3 Fig). Even for the top 10 donors, their percentage of total DAH on DAMH_CA

over the 8 years is pitifully small, from 0.03% in Canada to 2.69% in Finland (S3 Table). When

using the upper-bound estimates, the Global Fund to Fight AIDS, Tuberculosis and Malaria

(GFATM) appeared to be the largest donor (cumulatively US$551.3 million), with most of its

investments in providing psychological support and other medical and social care for high-

risk populations of HIV/AIDS, including drug users (S4 Fig).

Fig 2. DAMH_CA by year and sector (million, 2013 USD), lower-bound estimates. In this figure, we combined the

sectors “General Health” and “Population Program and Reproductive Health” in the original CRS dataset as “Health,”

the sectors “Humanitarian Aid” and “Multisector/Crosscutting” as “Humanitarian Aid,” and the sectors “Government

and Civil Society” and “Other Social Infrastructure and Services” as “Government and Civil Society.” CRS, Creditor

Reporting System; DAMH_CA, development assistance for child and adolescent mental health; USD, US dollar.

https://doi.org/10.1371/journal.pmed.1002524.g002

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PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 6 / 12

DAMH_CA per capita at the recipient country level, lower-bound

estimates

Fig 3 presents the world map of average annual per capita DAMH_CA for 132 countries.

Throughout the analysis period, 21 countries did not receive any funding on DAMH_CA,

including 3 low-income countries (Guinea-Bissau, Gambia, and Comoros), 8 lower middle–

income countries (e.g., Lesotho, Tonga, and Djibouti), and 10 upper middle–income countries

(e.g., Gabon, Namibia, and Botswana). Per capita, 69 countries received less than US$0.01

DAMH_CA, including 20 low-income countries (e.g. Rwanda, Mozambique, and Guinea), 26

lower middle–income countries (e.g., India, Senegal, and Nigeria), and 23 upper middle–

income countries (e.g., China, Mexico, and Chile). Only 14 countries received more than US

$0.05 DAMH_CA per capita, with 4 of them receiving more than US$0.2 per capita: West

Bank and Gaza Strip (US$2.9 per capita), Kiribati (US$1.3), Lebanon (US$0.4), and Bosnia

and Herzegovina (US$0.2). Numerical values of annual DAMH_CA per capita for each coun-

try (in both upper and lower bounds) are reported in S4 Table and S5 Table.

In different regions, projects that received a large amount of DAMH_CA often had differ-

ent targets. For example, in the Eastern Mediterranean and Europe, DAMH_CA projects with

a large amount of disbursements usually focused on alcohol addiction. DAMH_CA projects in

Middle Eastern countries (e.g., West Bank and Gaza Strip, Lebanon) were usually focused on

coping with trauma and providing psychological support to children and adolescents in con-

flicts. In Africa, a large amount of DAMH_CA was related to HIV/AIDS projects, which

included components addressing drug addiction and psychological care for children and ado-

lescents living with HIV.

Fig 3. Average annual per capita DAMH_CA disbursement between 2007 and 2015 in each country (2013 USD), lower-bound estimates. (1) The top 10 countries

with the highest average annual per capita DAMH_CA disbursement are West Bank and Gaza Strip (US$2.88), Kiribati (US$1.33), Lebanon (US$0.37), Bosnia and

Herzegovina (US$0.23), Samoa (US$0.16), Georgia (US$0.15), Jordan (US$0.13), Sri Lanka (US$0.11), Libya (US$0.11), and Central African Republic (US$0.11). (2)

We did not include unallocable or regional DAMH_CA projects. DAMH_CA, development assistance for child and adolescent mental health; USD, US dollar.

https://doi.org/10.1371/journal.pmed.1002524.g003

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DAMH_CA to suicide and five mental disorders, lower-bound

estimates

Interventions targeting the five leading causes for disability or death among children and ado-

lescents received relatively small disbursements. The lower-bound estimates show that the

cumulative amount of disbursements to trauma-related mental disorders accounted for 1.13%

of total DAMH_CA, followed by substance abuse (0.76%), autism (0.19%), suicide (0.02%),

depression (0.02%), and anxiety (0.01%) (see S9 Fig). Findings on investments in these disor-

ders remain similar when using upper-bound estimates (S5 Fig).

Discussion

Using the CRS data with a multi-sectoral perspective, we tracked 44 donors’ aid disbursements

to DAMH_CA projects implemented in 132 developing countries between 2007 and 2015.

The total amount of DAMH_CA with a primary target on the mental health of children and

adolescents was US$190.3 million over the 8 years, accounting for 12.5% of total DAMH and

0.1% of total DAH. Per capita, 90 developing countries received either 0 or less than US$0.01

average DAMH_CA, including 23 low-income countries (out of 36 total low-income countries

[64%]). Global child and adolescent mental health is truly the orphan of DAH. Our findings

are consistent with a recent publication on DAMH_CA [13].

Additional concerns we observed are related to volatility and poor targeting of assistance.

DAMH_CA experienced marked fluctuations over the 8-year period, mainly driven by the

investments from two donors. This poses challenges for effective long-term budgeting and

planning for recipient countries with high dependence on external sources for mental health

financing. Furthermore, it is alarming that both the total amount and proportion of

DAMH_CA for the public sectors has been comparatively very low (12.1% over the 8-year

period), with most DAMH_CA targeting temporary or short-term humanitarian assistance to

children and adolescents in disasters or conflicts and channeling the assistance through

NGOs. This is consistent with our previous study on DAMH, in which we also observed that

the share of DAMH channeled to public health sectors, the key player in delivering basic men-

tal health care, was small. Though there is mounting evidence that mental health services for

children and adolescents can be effectively delivered by community health workers [14], only

a tiny fraction of aid has been invested (US$14.2 million over the 8-year period) in delivering

mental health care to children and adolescents with priority mental health conditions.

This analysis has the following limitations. (1) Due to a lack of details of aid projects at the

recipient country level, our estimates did not include aid to developing countries from emerg-

ing economies (e.g., China), NGOs, or foundations (with the exception of the BMGF). (2) The

identification strategy was not able to capture all projects on DAMH_CA or those with typo-

graphical errors and solely relied on project descriptions provided by donors, which could be

subject to unreliable quality. (3) When estimating DAMH_CA at the country level, data that

could not be allocated to a specific recipient country were not included. (4) The estimates of

DAMH_CA for the specific mental disorders (e.g., depression) in the analysis could be under-

estimated, as projects with general mental health terms as key words (e.g., projects of “mental

health”) could also provide care to patients with depression but not be included in the current

estimates due to lack of information regarding separate funds for depression. (5) Our estima-

tion only focused on projects that either primarily or partially targeted mental health for chil-

dren and adolescents. We did not include projects that targeted socioeconomic determinants

of child and adolescent mental health, such as nutrition or maternal education; thus, our esti-

mates may largely reflect investments in selective prevention (e.g., children in humanitarian

contexts) or treatment and care.

Development assistance for child and adolescent mental health

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 8 / 12

Despite these limitations, this analysis is the first to report on the financing of mental health

care for children and adolescents in low- and middle-income countries (LMICs) between 2007

and 2015. We consider a number of key lessons to be drawn from this analysis. First, given the

evidence that much of the burden of mental disorders has its origins in childhood or adoles-

cence and early interventions are potentially the key to prevention and recovery [15,16], there

should be an increase, at least a doubling, in DAMH_CA so as to enable developing countries

to strengthen their capacity by investing in mental health infrastructure and training provid-

ers, including community health workers and specialists, to deliver cost-effective interven-

tions. We believe that challenging the stigma associated with mental disorders, providing

accurate information about the prevalence and impact of mental disorders in children and

adolescents, and cost-effectiveness of interventions will raise interest in investing in mental

health among the donor community. Second, investments should be based on scientific evi-

dence of the patterns of the burden of disease, cost-effective interventions, and a recipient

country’s own sociocultural context. For example, as community-based delivery of psychoso-

cial interventions by frontline workers has been shown to be cost-effective in LMICs, more

funds should be directed to this approach. Third, while it is important for donors to continue

supporting humanitarian assistance for those living in conflict areas, there should be more

donor investments, with more stability and better targeting for building and sustaining mental

health programs to achieve universal mental health coverage in the long term. In particular,

funding should target the public system to ensure that the goals of integrating mental health

interventions (promotional, preventive, or curative) into appropriate platforms for delivery,

including health, education, and social sectors, are achieved [17].

Supporting information

S1 Text. Data sources and identification strategy.

(DOCX)

S1 Table. One hundred thirty-two recipients in the CRS (according to the World Bank

income classification in 2010). CRS, Creditor Reporting System.

(XLSX)

S2 Table. Key words used to search DAMH_CA projects in the CRS, 2007–2015. CRS,

Creditor Reporting System; DAMH_CA, development assistance for child and adolescent

mental health.

(XLSX)

S3 Table. Top 10 DAMH_CA donors: DAMH_CA (lower bound) as a percentage of their

DAH over the 8 years. DAH, development assistance for health; DAMH_CA, development

assistance for child and adolescent mental health.

(XLSX)

S4 Table. Annual DAMH_CA disbursements per capita (2013 USD) to each recipient

country between 2007 and 2015, lower-bound estimates. DAMH_CA, development assis-

tance for child and adolescent mental health; USD, US dollar.

(XLSX)

S5 Table. Annual DAMH_CA disbursements per capita (2013 USD) to each recipient

country between 2007 and 2015, upper-bound estimates. DAMH_CA, development assis-

tance for child and adolescent mental health; USD, US dollar.

(XLSX)

Development assistance for child and adolescent mental health

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 9 / 12

S1 Box. Definition of sectors in CRS data. CRS, Creditor Reporting System.

(DOCX)

S1 Fig. Annual proportion of DAMH_CA in total DAH between 2007 and 2015, lower-

bound estimates. DAH, development assistance for health; DAMH_CA, development assis-

tance for child and adolescent mental health.

(TIFF)

S2 Fig. Annual DAMH_CA (million, 2013 USD) by channel between 2007 and 2015,

lower-bound estimates. UN organizations include UN, UNFPA, UNICEF, UNDP, UNAIDS,

and UNECE. DAMH_CA, development assistance for child and adolescent mental health; EU,

European Union; UN, United Nations; UNAIDS, the Joint United Nations Programme on

HIV and AIDS; UNDP, United Nations Development Programme; UNECE: United Nations

Economic Commission for Europe; UNFPA, United Nations Population Fund; UNICEF,

United Nations Children’s Fund; USD, US dollar.

(TIFF)

S3 Fig. Annual DAMH_CA (million, 2013 USD) by donor between 2007 and 2015, lower-

bound estimates. DAMH_CA, development assistance for child and adolescent mental health;

USD, US dollar.

(TIFF)

S4 Fig. Annual DAMH_CA (million, 2013 USD) by donor between 2007 and 2015, upper-

bound estimates. DAMH_CA, development assistance for child and adolescent mental health;

USD, US dollar.

(TIFF)

S5 Fig. Cumulative DAMH_CA disbursement (million, 2013 USD) of suicide and mental

disorders and their percentages in total DAMH_CA between 2007 and 2015, lower-bound

estimates. The DAH to each health focus shown in this figure is not mutually exclusive. For

example, if a project is for both anxiety and depression, we included this project in the estima-

tion of both health focuses. DAH, development assistance for health; DAMH_CA, develop-

ment assistance for child and adolescent mental health; USD, US dollar.

(TIFF)

S6 Fig. DAMH_CA by year (million, 2013 USD) and DAMH_CA disbursements as per-

centages of total DAMH between 2007 and 2015, upper-bound estimates. DAMH, develop-

ment assistance for mental health; DAMH_CA, development assistance for child and

adolescent mental health; USD, US dollar.

(TIFF)

S7 Fig. Annual DAMH_CA (million, 2013 USD) by sector (combined) between 2007 and

2015, upper-bound estimates. In this figure, we combined the sectors of “General Health”

and “Population Program and Reproductive Health” in the original CRS dataset as “Health,”

the sectors of “Humanitarian Aid” and “Multisector/Crosscutting” as “Humanitarian Aid,”

and the sectors of “Government and Civil Society” and “Other Social Infrastructure and Ser-

vices” as “Government and Civil Society.” CRS, Creditor Reporting System; DAMH_CA,

development assistance for child and adolescent mental health; USD, US dollar.

(TIFF)

S8 Fig. Annual DAMH_CA (million, 2013 USD) by channel between 2007 and 2015,

upper-bound estimates. UN organizations include UN, UNFPA, UNICEF, UNDP, UNAIDS,

and UNECE. DAMH_CA, development assistance for child and adolescent mental health; EU,

Development assistance for child and adolescent mental health

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002524 March 9, 2018 10 / 12

European Union; UN; United Nations; UNAIDS, the Joint United Nations Programme on

HIV and AIDS; UNDP, United Nations Development Programme; UNECE, United Nations

Economic Commission for Europe; UNFPA; United Nations Population Fund; UNICEF,

United Nations Children’s Fund; USD, US dollar.

(TIFF)

S9 Fig. Per capita DAMH_CA disbursement (2013 USD) between 2007 and 2015 in each

country, upper-bound estimates. We did not include unallocable or regional DAMH_CA

projects. DAMH_CA, development assistance for child and adolescent mental health; USD,

US dollar.

(TIF)

S10 Fig. Cumulative DAMH_CA disbursement (million, 2013 USD) between 2007 and

2015 by health focus, upper-bound estimates. DAMH_CA, development assistance for child

and adolescent mental health; USD, US dollar.

(TIF)

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